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<br /> <br /> 31 <br />If Yes: Agency or Court: <br />Address: <br />Telephone Number: <br />Signature: _________________________________________ <br />Date: ________________________________ <br /> <br />Return to: <br />Suzanne Fischer <br />Elk River Community Operations and Development Director/ADA Coordinator <br />13065 Orono Parkway <br />Elk River, MN 55330 <br />sfischer@ElkRiverMN.gov <br /> <br />NOTICE OF RIGHTS <br />In accordance with the Minnesota Government Data Practices Act, Elk River is required to inform you of your rights as they <br />pertain to the private information collected from you. Your personal information we collect from you is private. Access to this <br />information is available only to you and the agency collecting the information and other statutorily authorized agencies, unless <br />you or a court authorizes its release. <br />The Minnesota Government Data Practices Act requires that you be informed that the following information, which you are <br />asked to provide, is considered private. <br /> <br />The purpose and intended use of the requested information is: <br />To assist city staff and designees to evaluate and respond to accessibility concerns within the public right of way. <br /> <br />Authorized persons or agencies with whom this information may be shared include: <br />Elk River officials, staff or designee <br /> <br />Furnishing the above information is voluntary, but refusal to supply the requested <br />information will mean: <br /> <br />City staff may be unable to respond to or evaluate your request. <br />MINN. STAT. §13.04(2) <br />